Abortion pill shifts focus off Roe's fate

Even if the John Roberts-led court overturns the 1973 ruling, a return to back-alley procedures is unlikely.

October 9, 2005|By John Leland the New York Times

With the confirmation last week of John G. Roberts Jr. as chief justice of the United States, eyes turned to President Bush's next Supreme Court nominee, Harriet Miers, who, on a closely divided court, may determine the fate of Roe v. Wade, the 1973 decision that recognized a woman's right to an abortion.

But such speculation overlooks a paradox in the abortion wars: While combatants focus on the law, technology is already changing the future of abortion, with or without the Supreme Court.

Even if the court restricts or eliminates the right to an abortion, the often-raised specter of a return to back-alley abortions is not likely to be realized, said Dr. Beverly Winikoff, president of Gynuity Health Projects, a nonprofit group that supports access to abortion.

"The conditions that existed before 1973 were much different than what they are in 2005," she said. "We have better antibiotics now and better surgical treatments."

But no change is bigger than the advent of an inexpensive drug called misoprostol, which the federal Food and Drug Administration approved for treatment of ulcers in 1988, but which has been used in millions of self-administered abortions worldwide.

If the Supreme Court overturns Roe v. Wade, freeing states to ban abortion, this common prescription drug, often known by the brand name Cytotec, could emerge as a cheap, relatively safe alternative to the practices that proliferated before Roe.

"We won't go back to the days of coat hangers and knitting needles," said Dr. Jerry Edwards, an abortion provider in Little Rock, Ark. "Rich women will fly to California; poor women will use Cytotec."

Because it was never intended for use in abortions, it has not been widely tested for safety and effectiveness.

In 2000, researchers at three obstetrics and gynecology clinics in New York noted that low-income immigrant women were already using misoprostol as an alternative to going to an abortion clinic, because it was easier and less expensive. They got the pills from doctors, pharmacies, relatives and from contacts in other countries.

The drug causes the uterus to contract and, if the contractions are strong enough, to expel the embryo or fetus. In the United States, misoprostol is typically used off-label with the abortion drug RU-486 in nonsurgical abortions and in some surgical abortions.

A spokeswoman for Pfizer, which sells Cytotec, said the company does not comment on off-label use. Last year, Americans filled 365,000 prescriptions of misoprostol for ulcers, according to IMS Health, a pharmaceutical-consulting firm.

A dose sufficient to cause an abortion costs less than $2, said Dr. John K. Jain, an associate professor of obstetrics and gynecology at the University of Southern California, who has performed limited clinical trials of abortions using misoprostol alone. He said he found it was effective 80 percent to 90 percent of the time, if administered by a doctor. This is slightly lower than its effectiveness in combination with RU-486.

Misoprostol is usually used in the first trimester, but under clinical conditions, Jain and other researchers say it has been used safely in the second trimester. Women taking it on their own risk greater rates of failure and higher side effects, including nausea, vomiting, diarrhea and fever and chills.

Carrie Gordon Earll, a senior analyst of bioethics at Focus on the Family, which supports a reversal of Roe v. Wade, said the existence of new technologies such as misoprostol should have no bearing on the law.

"The law operates as a teacher in a moral sense," regardless of people's opportunity to break it, she said. "Even if you have some people who get a drug off the black market and sell it to women, that doesn't mean we don't have a policy to discourage abortion."

In Brazil, where abortion is banned except in rare circumstances, misoprostol is the method of choice for up to 90 percent of all abortions, said Alessandra Chacham, a professor of sociology at the University of the State of Minas Gerais who studies reproductive health in Brazil. In the late 1980s and early 1990s, she said, pregnant women started to spread the word, because the drug's label warned that it could cause miscarriages.

Compared with illegal abortions using other methods, the rate of infection with misoprostol was 12 times lower, researchers have found. But researchers at the University of Rio de Janeiro reported that they also found that among babies born with certain birth defects, a high percentage of the mothers used misoprostol. When the government in response restricted access to misoprostol, drug smugglers created a black market, Chacham said.

But American women may not be as receptive, said Norma McCorvey, who in 1973 was known as Jane Roe, the woman who brought the case that legalized abortion but who has since argued for the reversal of the court's decision.